Bariatric Surgery Resources
- Bariatric Surgery 101
- Risks of Weight Loss Surgery
- Types of Bariatric Surgery
- Plastic Surgery Post Operation
Understanding the Gastrointestinal Tract
To better understand how weight loss surgery produces change, it is important to understand how your gastrointestinal tract functions. As the food you consume moves through the tract, various digestive juices and enzymes are introduced at specific stages that allow absorption of nutrients. Food material that is not absorbed is then prepared for elimination. A simplified description of the gastrointestinal tract appears below. Your doctor can provide a more detailed description to help you better understand how weight loss surgery works.
- The esophagus is a long muscular tube, which moves food from the mouth to the stomach.
- The abdomen contains all of the digestive organs.
- The stomach, situated at the top of the abdomen, normally holds just over 3 pints (about 1500 ml) of food from a single meal. Here the food is mixed with an acid that is produced to assist in digestion. In the stomach, acid and other digestive juices are added to the ingested food to facilitate the breakdown of complex proteins, fats, and carbohydrates into small, more absorbable units.
- A valve at the entrance to the stomach from the esophagus allows the food to enter while keeping the acid-laden food from “refluxing” back into the esophagus, causing damage and pain.
- The pylorus is a small round muscle located at the outlet of the stomach and the entrance to the duodenum (the first section of the small intestine). It closes the stomach outlet while food is being digested into a smaller, more easily absorbed form. When food is properly digested, the pylorus opens and allows the contents of the stomach into the duodenum.
- The small intestine is about 15 to 20 feet long (4.5 to 6 meters) and is where the majority of the absorption of the nutrients from food takes place. The small intestine is made up of three sections: the duodenum, the jejunum and the ileum.
- The duodenum is the first section of the small intestine and is where the food is mixed with bile produced by the liver and with other juices from the pancreas. This is where much of the iron and calcium is absorbed.
- The jejunum is the middle part of the small intestine extending from the duodenum to the ileum; it is responsible for digestion.
- The last segment of the intestine, the ileum, is where the absorption of fat-soluble vitamins A, D, E and K and other nutrients are absorbed.
- Another valve separates the small and large intestines to keep bacteria-laden colon contents from coming back into the small intestine.
- In the large intestines, excess fluids are absorbed and a firm stool is formed. The colon may absorb protein, when necessary.
Development of Surgical Treatments for Obesity
The concept for bariatric surgery, or the surgical treatment of obesity, came about somewhat serendipitously. In the course of removing large portions of the stomach or small intestine in patients with cancer or severe ulcers, surgeons noticed an interesting trend. The patients tended to lose weight. Over the past 50 years, numerous world-class surgeons have taken part in exploring this concept. As with anything, there was a learning curve. But the mistakes and shared global data have helped other innovators to improve upon the techniques and bring bariatric surgery into the modern age. The bariatric surgery procedures available today have either stood the test of time or drawn from the lessons learned by the early pioneers. As a result, bariatric surgery treatment for obesity has never been as safe or as effective. In Summary, Bariatric patients have more choices than ever, not to mention better and safer ones. Operative mortality for most contemporary weight loss surgeries has fallen to less than 1% while permanent and significant weight loss has been achieved in multiple published reports. For the growing population of morbidly obese Americans, bariatric surgery has cemented its place as the most effective weight loss treatment available.
Bariatric Surgery as Treatment for Obesity
There is considerable misinformation concerning the validity of bariatric surgery in the management of morbid obesity. Bariatric Surgery (also referred to as “gastric surgery”, “obesity surgery”, “stomach stapling”, and “gastric bypass”) has been endorsed by the National Institutes of Health Consensus Conference, 1992. The American Society for Bariatric Surgery is recognized by the American College of Surgeons and a specialty surgical society in the Specialty & Service Society section of the American Medical Association. It must be emphasized that these procedures are in no way to be considered as cosmetic surgery.
The American Society for Bariatric Surgery reports surgical treatment is medically necessary because it is the only proven method of achieving long term weight control for the morbidly obese. Surgical treatment is not a cosmetic procedure. Bariatric surgery involves reducing the size of the gastric reservoir, with or without a degree of associated malabsorption. Eating behavior improves dramatically. (1) This reduces caloric intake and ensures that the patient practices behavior modification by eating small amounts slowly, and chews each mouthful well.
Current medical standards suggest that patients whose BMI exceed 40 (or 35-39 with life threatening co-morbidities) are potential candidates for weight loss surgery if they strongly desire substantial weight loss because obesity morbidly impairs the quality of their lives. They must clearly and realistically understand how their lives may change after the operation.
The American Society for Bariatric Surgery reports that weight loss usually reaches a maximum between 18 and 24 months postoperatively. Mean percent excess weight loss at five years ranged from 48 to 74% after gastric bypass and from 50 to 60% after vertical banded gastroplasty. In a study of over 600 patients following gastric bypass, with 96% follow-up, mean percent excess weight loss still exceeds 50% after fourteen years. Another 10-year follow-up series from the University of Virginia report weight loss of 60% of excess weight at 5 years and in the mid 50’s between years 6 and 10. Multiple other authors have reported 5 and 6-year follow-up of their patient series with similar weight loss results.
The American Society for Bariatric Surgery reports weight reduction surgery has been reported to improve several co morbid conditions such as glucose intolerance and frank diabetes mellitus, sleep apnea and obesity associated hypoventilation, hypertension, and serum lipid abnormalities. A recent study showed that Type II diabetics treated medically had a mortality rate three times that of a comparable group who underwent gastric bypass surgery. Also, preliminary data indicate improved heart function with decreased ventricular wall thickness and decreased chamber size with sustained weight loss. Other benefits observed in some patients after surgical treatment include improved mobility and stamina. Many patients note a better mood, self-esteem, interpersonal effectiveness, and an enhanced quality of life. They are able to explore social and vocational activities formerly inaccessible to them. Self-body image disparagement decreases.
1. Rand CS, Macgregor AM, Hankins GC. Eating behavior after gastric bypass surgery for obesity. South Med J 1987; 80(8): 961-4.
How Effective Is Weight Loss Surgery?
- The actual weight a patient will lose after the weight loss surgery is dependent on several factors. These include:
- Patient’s age
- Weight before weight loss surgery
- Overall condition of patient’s health
- Surgical procedure
- Ability to exercise
- Commitment to maintaining dietary guidelines and other follow-up care
- Motivation of patient and cooperation of their family, friends, and associates
In general, weight loss surgery success is defined as achieving loss of 50% or more of excess body weight and maintaining that level for at least five years. Clinical data will vary for each of the different procedures mentioned on this site. Results may also vary by surgeon. Ask your doctor for the clinical data stating their results of the procedure they are recommending.
Clinical studies show that, following weight loss surgery, most patients lose weight rapidly and continue to do so until 18 to 24 months after the procedure. Patients may lose 30 to 50% of their excess weight in the first six months and 77% of excess weight as early as 12 months after weight loss surgery. Another study showed that patients can maintain a 50-60% loss of excess weight 10-14 years after weight loss surgery. Patients with higher initial BMIs tend to lose more total weight. Patients with lower initial BMIs will lose a greater percentage of their excess weight and will more likely come closer to their ideal body weight.
Patients with Type 2 Diabetes tend to show less overall excess weight loss than patients without Type 2 Diabetes. Weight loss surgery has been found to be effective in improving and controlling many obesity-related health conditions. A 2000 study of 500 patients showed that 96% of certain associated health conditions studied (back pain, sleep apnea, high blood pressure, diabetes, and depression) were improved or resolved. For example, many patients with Type 2 Diabetes, while showing less overall excess weight loss, have demonstrated excellent resolution of their diabetic condition, to the point of having little or no need for continuing medication.
How Bariatric Surgery Produces Change
Surgeons first began to recognize the potential for weight loss surgery while performing operations that required the removal of large segments of a patient’s stomach and intestine. After the surgery, doctors noticed that in many cases patients were unable to maintain their pre-surgical weight. With further study, surgeons were able to recommend similar modifications that could be safely used to produce weight loss in morbidly obese patients. Over the last decade, these procedures have been continually refined in order to improve results and minimize risks. Today’s bariatric surgeons have access to a substantial body of clinical data to help them determine which weight loss surgeries should be used and why.
Today, the American Society for Bariatric Surgery describes two basic approaches that weight loss surgery takes to achieve change:
- Restrictive procedures that decrease food intake.
- Malabsorptive procedures that alter digestion, thus causing the food to be poorly digested and incompletely absorbed so that it is eliminated in the stool.
Making Your Decision about Weight Loss Surgery
Weight loss surgery is major surgery. Although most patients enjoy an improvement in obesity-related health conditions (such as mobility, self-image, and self-esteem) after the successful results of weight loss surgery, these results should not be the overriding motivation for having the procedure. The goal is to live better, healthier and longer.
That is why you should make the decision to have weight loss surgery only after careful consideration and consultation with an experienced bariatric surgeon or a knowledgeable family physician. A qualified surgeon should answer your questions clearly and explain the exact details of the procedure, the extent of the recovery period and the reality of the follow-up care that will be required. They may, as part of routine evaluation for weight loss surgery, require that you consult with a dietician/nutritionist and a psychiatrist/therapist. This is to help establish a clear understanding of the post-operative changes in behavior that are essential for long-term success.
It is important to remember that there are no ironclad guarantees in any kind of medicine or surgery. There can be unexpected outcomes in even the simplest procedures. What can be said, however, is that weight loss surgery will only succeed when the patient makes a lifelong commitment. Some of the challenges facing a person after weight loss surgery can be unexpected. Lifestyle changes can strain relationships within families and between married couples. To help patients achieve their goals and deal with the changes surgery and weight loss can bring, most bariatric surgeons offer follow-up care that includes support groups, dieticians and other forms of continuing education.
Ultimately, the decision to have the procedure is entirely up to you. After having heard all the information, you must decide if the benefits outweigh the side effects and potential complications. This surgery is only a tool. Your ultimate success depends on strict adherence to the recommended dietary, exercise and lifestyle changes.
Preparing For Weight Loss Surgery
Weight loss surgery is like other major surgeries. The best preparation is to understand the risks and potential benefits and to closely follow your doctor’s instructions.
- To mentally prepare yourself:
- Understand weight loss surgery and what to expect afterward.
- Talk to people who have had weight loss surgery.
- Write a letter to yourself and your surgeon explaining your reasons for wanting weight loss surgery and outlining your plans to maintain your weight loss after surgery.
- Start a journal about your experience. Record how you feel now, the obstacles you encounter, the things you hope to be able to do after surgery.
- Get a letter of support from your family. It helps to know you have people behind you, waiting to help.
- To physically prepare yourself, strictly follow your doctor’s guidelines. These usually include, but are not limited to:
- Restricting yourself to a clear liquid diet 12-24 hours before surgery.
- Stop smoking for at least a month before surgery.
- Be certain to follow your surgeon’s instructions regarding any medications you may be taking to control other health conditions.
- Arrive on time, with supplies from home for a three- to four-day hospital stay. If you use special equipment for sleep apnea, you should bring your machine to the hospital.
Post-Surgery Diet Modifications
The modifications made to your gastrointestinal tract will require permanent changes in your eating habits that must be adhered to for weight loss success. Post-surgery dietary guidelines will vary by surgeon. You may hear of other patients who are given different guidelines following their weight loss surgery that encourage weight loss success. It is important to remember that every surgeon does not perform the exact same weight loss surgery procedure and that the dietary guidelines will be different for each surgeon and each type of procedure. What is most important is that you adhere strictly to your surgeon’s recommended guidelines so you too can achieve the weight loss success you desire. The following are some of the generally accepted dietary guidelines a weight loss surgery patient may encounter:
- GUIDELINES FOR WEIGHT LOSS SUCCESS
- When you start eating solid food it is essential that you chew thoroughly. You will not be able to eat steaks or other chunks of meat if they are not ground or chewed thoroughly.
- Don’t drink fluids while eating. They will make you feel full before you have consumed enough food.
- Omit desserts and other items with sugar listed as one of the first three ingredients.
- Omit carbonated drinks, high-calorie nutritional supplements, milk shakes, high-fat foods and foods with high fiber content.
- Avoid alcohol.
- Limit snacking between meals.
This information provided by Ethicon Endo-Surgery Inc.
Surgical Weight Loss Support Groups
Weight loss support groups are an intricate part of your recovery from surgery and long-term weight loss maintenance. Weight loss support groups are forums that provide education, motivation, and can provide valuable input pre-operatively as well as postoperatively.
Weight loss support groups are conducted at various times, days and locations. An experienced health professional, physician and successful surgical weight loss patients put on the meetings. Support groups are hosted in a variety of ways. Many weight loss support groups provide speakers who discuss issues of interest while others lead their own educational speaking engagements or have group discussions. The support groups are for those that are doing well with their surgical procedure, those investigating surgery and those that may be struggling with their program.
Some weight loss support groups are held in the community setting and other support groups are provided by your surgeon. You are encouraged to get such information from his office.
Risks of Weight Loss Surgery
Weight loss surgery should not be considered until you and your doctor has evaluated all other options. As with all surgeries, there are risks associated with this procedure. If complications occur during the operation, your doctor may choose to perform open surgery. Your doctor must determine if you are an appropriate surgical candidate.
Weight loss surgery is typically reserved for those individuals 100 pounds or more overweight (Body Mass Index [BMI] of 40 or higher) who have not responded to other less invasive therapies such as diet, exercise, medications, etc.
In certain circumstances, less morbidly obese patients (with BMIs between 35 and 40) may be considered for surgery (patients with high-risk comorbid conditions and obesity-induced physical problems that are interfering with the quality of life).
Weight loss surgery should not be considered until you and your doctor has evaluated all other options. The proper approach to weight loss surgery requires discussion and careful consideration of the following with your doctor:
These procedures are in no way to be considered as cosmetic surgery.
The surgery does not involve the removal of adipose tissue (fat) by suction or excision.
A decision to elect surgical treatment requires an assessment of the risk and benefit to the patient and the meticulous performance of the appropriate surgical procedure.
These weight loss surgical procedures (approved in the United States) are not reversible.
The success of weight loss surgery is dependent upon long-term lifestyle changes in diet and exercise.
Problems may arise after surgery that may require revisions. The success of surgical treatment must begin with realistic goals and progress through the best possible use of well-designed and tested operations.
Complications and Risks
As with any surgery, there are operative, short-term, and long-term complications and risks associated with weight loss surgical procedures that should be discussed with your doctor.
The risks of this surgery depend in great part on your general medical condition. Each patient is different and must be personally evaluated by a surgeon and possibly specialists, to determine the particular risks. Studies demonstrate that obesity is associated with higher surgical risks. As with all major abdominal surgical procedures, there are risks inherent to anesthesia and the surgical process, including the potential for respiratory, neurological, cardiovascular abnormalities, blood clot formation, hemorrhage, infection, and even death. The risks of obesity may cause this same anesthesia and surgical risks to be even higher.
Immediate postoperative problems may include: leakage of intestinal contents and fluids at the surgical sites, infection, respiratory complications, the need for cardiopulmonary, renal, and other intensive care support, re-operation, or even death.
Short-term complications from weight loss surgical procedures are possible. The following information is from the International Bariatric Surgery Registry (IBSR), Winter 2000-2001 Pooled Report 15. Gastrointestinal surgery for severe obesity. Proceedings of a National Institutes of Health Consensus Development Conference. March 25-27, 1991, Bethesda, MD. Am J Clin Nutr, 1992. 55(2 Suppl): p. 487S-619S.See also American Society of Bariatric Surgeons.
|Complications from gastric bypass within 30 days of surgical treatment for obesity of 10, 993 people. Total patients from IBSR 2000-2001 Winter Pooled Report 15(1)||N||%||Minor:*||Major:*|
|Minor:*||other: drug skin problems, balloon dilatation, hemorrhoidectomy, gastroenteritis, undefined||165||1.50%||1.50%||0.00%|
|Minor:*||atelectasis (46), hyperventilation (1), respiratory undefined (104)||151||1.37%||1.37%||0.00%|
|Minor:*||wound site Seroma (80), wound infection (48)||128||1.17%||1.17%||0.00%|
|Minor:*||pleural effusion (11), pleuritis (2), pneumonitis (9),||22||0.20%||0.20%||0.00%|
|Minor:*||renal, urinary tract infection (4)||7||0.06%||0.06%||0.00%|
|Minor:*||stoma too large (5), stoma too small (1)||6||0.05%||0.05%||0.00%|
|Minor:*||ulcers: duodenal, gastric, stomal (jejunum or anastomoses)||5||0.05%||0.05%||0.00%|
|Minor:*||hepatic, liver hematoma (1)||4||0.04%||0.04%||0.00%|
|Minor:*||esophageal reflux, esophagitis (2)||3||0.03%||0.03%||0.00%|
|Minor:*||hernia: incisional (1), ventral (1)||2||0.02%||0.02%||0.00%|
|Minor:*||dumping syndrome (1), vitamin insufficiency (1)||2||0.02%||0.02%||0.00%|
|Major:*||GI Leak (5 deaths)||33||0.30%||0.00%||0.30%|
|Major:*||stoma obstruction (lumenal – 18); stoma stenosis (15)||33||0.30%||0.00%||0.30%|
|Major:*||GI hemorrhage or GI bleeding; 7 due to ulcers, undefined (19)||26||0.24%||0.00%||0.24%|
|Major:*||cardiac (4 deaths)||19||0.17%||0.00%||0.17%|
|Major: *||pulmonary embolism (11 deaths)||19||0.17%||0.00%||0.17%|
|Major: *||respiratory arrest or failure (4 deaths)||16||0.15%||0.00%||0.15%|
|Major:*||small bowel obstruction: Roux-en-y (4), common channel (2), enterostomy (1) undefined (6)||13||0.12%||0.00%||0.12%|
|Major:*||Subphrenic / sub hepatic abscess; abdominal abscess (1)||11||0.10%||0.00%||0.10%|
|Major:*||gastric dilatation (1 death)||11||0.10%||0.00%||0.10%|
|Major:*||deep venous thrombosis (6), thrombophlebitis (2)||8||0.07%||0.00%||0.07%|
|Major:*||staple line breakdown: linear gastric (3), window (1), enterostomy (3 – 2 deaths)||7||0.06%||0.00%||0.06%|
|Major:*||pancreatitis (3); acute cholecystitis (2)||5||0.05%||0.00%||0.05%|
|Major:*||neurologic (1 death)||4||0.04%||0.00%||0.04%|
|Major:*||peritonitis (2 deaths)||2||0.02%||0.00%||0.02%|
Gastric Bypass Surgery Complications: 14-Year Follow-UpWeight loss surgery involves some loss of absorptive function, therefore, the long-term consequences of potential nutrient deficiencies must be recognized and adequate monitoring must be performed, particularly with regard to vitamin B12, folate, and iron. Some patients may develop other gastrointestinal symptoms such as “dumping syndrome” or gallstones. Occasionally, patients may have postoperative mood changes or their pre-surgical depression symptoms may not be improved by the achieved weight loss. Thus, surveillance should include monitoring of indices of inadequate nutrition and modification of any pre operative disorders. The table below illustrates some of the complications that can occur following gastric bypass surgery.
|Vitamin B12 deficiency||239||39.9|
|Readmit for various reasons||229||38.2|
|Staple line failure||90||15.0|
Data derived from source (Pories WJ (595)) and modified based on personal communications.
This information is taken from the Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults: The Evidence Report published by the National Institutes of Health, National Heart, Lung, and Blood Institute in June 1998.
The intent of the guidelines is to provide the current scientific evidence on the most appropriate treatment strategies for the overweight and obese patient and to report on the effects of such treatments in a way that constitutes evidence-based clinical guidelines for primary health care practitioners. The guidelines should also be useful for managed care organizations or other groups that define benefit plans for patients or handle health care resources. In addition, the systematic assessment of the literature should be a valuable resource to health care policy makers and clinical investigators.
What is StomaphyX?
The StomaphyX device is an endoluminal fastener and delivery system that consists of an ergonomic, flexible fastener delivery device and sterile polypropylene fastener implants.
The procedure to insert the StomaphyX device is the first FDA-approved non-invasive bariatric procedure for weight loss.
Using a fiberoptic gastroscope the esophagus and stomach are easily accessed. The StomaphyX device is designed to go down into the stomach with the fiberoptic endoscope. Once inside the stomach pouch, the StomaphyX tool pleats and staples the stomach to make the pouch smaller.
StomaphyX may benefit:
- Gastric Bypass patients who have regained weight or want to lose more weight
- Duodenal Switch patients who want more restriction
- Sleeve Gastrectomy patients who want more restriction in the remaining stomach
StomaphyX features include:
- Transoral insertion
- Delivers unlimited fasteners with single insertion
- Adjustable and /or revisable transorally
- No abdominal incisions
- No internal incisions
What is The Duodenal Switch Procedure?
The Duodenal Switch procedure is a major surgery that rearranges the intestines so that the majority of food calories are not absorbed, resulting in progressive, long-term weight loss in most obese persons. It is important to be aware that many physical, social, and emotional changes occur as a result of this surgery.
The risks, as well as the benefits, must be understood.
Our staff will gladly discuss variations for your individual situation, along with any other questions you may have.
Normal Digestion – How Our Bodies Process Food
The complex fats, proteins, and carbohydrates are broken down into simpler fatty acids, amino acids, and sugars. Only the simple “building blocks” are then absorbed as they continue to pass through the small intestine. These basic end products of digestion are then absorbed as they continue to pass through the small intestine. These basic end products of digestion are then used for fuel or stored as fat.The food you ingest first enters your stomach, where hydrochloric acid and some enzymes begin the digestive process. In the next stage, the food enters the duodenum, the first portion of the small intestine, where it mixes with bile and additional enzymes produced by the intestinal lining and the pancreas.
How the Duodenal Switch Procedure is Performed
- The duodenum is divided to the point where it connects to the stomach and where it connects to the bile ducts. The purpose is to divert pancreatic juice and bile. The lower end of the duodenum is then closed.
- A portion of the stomach is removed to create a pouch with a capacity of about six ounces.
- A segment of the small intestine is divided. Note that no portion of the intestine is removed. Using this separated section of small intestine, a new connection is made to the open end of the duodenum.
- The remaining end of the divided small intestine is reattached approximately 30 inches from the colon. This biliopancreatic segment now carries the digestive enzymes and bile. Thus, food travels along one section of intestine and the digestive juices (enzymes and bile) travel along a separate section of the intestine. The food and digestive juices now mix in a short 30-inch section of the intestine where most of the digestion and absorption of nutrients will take place. This significantly reduces the amount of fat emulsification and absorption and reduces calories absorbed as well.
- The food then moves into the large intestine (colon). Absorption of calories has been essentially completed; mainly water is absorbed during this final stage.
- The gallbladder is removed if still present because many people who don’t already have a diseased gallbladder tend to form gallstones while they lose weight.
- The appendix, if present, is often removed. Note that the gallbladder, appendix and a portion of the stomach cannot be put back as they are permanently removed. However, none of the small or large intestines is removed, and therefore the intestinal rearrangement is completely reversible.
How Does the Surgery Work?
The immediate result of the surgery is a restriction of food intake due to the smaller stomach size; this assists the initial weight loss. Within 18 months the stomach pouch will gradually stretch to hold a normal-size meal. Weight loss will taper off and stabilize. An added benefit of stomach size reduction is decreased stomach acid production, thereby reducing the chances of ulcer formation.
Additionally, fewer calories are absorbed in the abbreviated 30-inch section of small bowel where food and digestive juices combine. This results in continued weight loss due to malabsorption. In the first 18 months after surgery, fats are incompletely absorbed, proteins are somewhat more absorbed, and simple sugars are completely absorbed. As the bowel naturally accommodates the surgery, fats will continue to be incompletely absorbed, but both protein and carbohydrate absorption generally increase over time.
Besides the previously listed effects, blood levels of cholesterol and triglycerides will be reduced, often to normal or even lower levels, due to the reduced absorption of fats. In diabetes, blood sugar levels will often become normal, and insulin requirements reduced or eliminated altogether. Similarly, medication for high blood pressure can often be discontinued as weight is lost.
All abdominal operations carry the risks of bleeding, infection in the incision, thrombophlebitis of legs (blood clots), lung problems (pneumonia, pulmonary embolisms), strokes or heart attacks, anesthetic complications, and blockage or obstruction of the intestine. These risks are greater in morbidly obese patients. Effective medical and nursing procedures used during and after the surgery have contributed to a successful outcome in the majority of obese patients.
In addition, several problems related to this specific surgical procedure are possible, although uncommon. One of these is the injury to the spleen during surgery, which could require removal of the spleen. Leakage of fluid from the stomach or intestine through the staples or sutures may occur which may result in abdominal infection; this could require additional surgery for repair and for drainage of infection. Narrowing of intestinal connections may occur, which could require a second surgery to widen the opening.
Possible late complications related to this surgery could include peptic ulcer; intestinal obstruction due to adhesions; vitamin deficiencies or anemia from insufficient absorption of iron or vitamins, low blood proteins from malabsorption, resulting in fluid retention; a hernia in the abdominal incision; temporary hair thinning due to changes in protein metabolism. Specific diet, physical activity, vitamin supplements, and medications may be recommended.
Morbidly obese patients are at higher risk for all surgical and anesthetic complications. Accordingly, extra precautions are taken before, during, and after the operation. Historic data show an approximately 0.5% (1 in 200) chance of death from obesity surgery nationally.
The Vertical Gastrectomy creates a banana shaped stomach by resecting the lateral aspect of the stomach. This reduces the stomach capacity from about 16 ounces to less than 4 ounces in size. The pylorus, vagus nerves and antral pump are all intact preserving the functional integrity of the stomach.
How it Works
Similar to the DS, the patients lose weight related to the reduced stomach size. Patients may then be able to adjust their eating behavior and maintain this weight loss, however, if they start to gain weight due to the expansion of the stomach over time, discussion of conversion to the DS can then be entertained.
This is purely a restrictive procedure and as such, one does not have to take additional vitamins and supplements except a multivitamin. Like the DS, normal gastric emptying is maintained and dumping does not occur. Marginal ulcers also do not occur and these patients tolerate aspirin and NSAIDS, which are commonly not tolerated with conventional RGB. It is also an operation which can be performed laparoscopically in about 1 hour, giving the highest risk patients the ability to proceed with weight loss surgery when the other more involved procedures would be contraindicated.
Although the same risks are present, the chance of a leak is extremely low as there are no anastomoses done. In addition, most postoperative problems are related to the length of surgery, blood loss, fluid shifts, etc. In this procedure, because of its simplicity, the risks of these complications are reduced.
Jejuno-Illeal Bypass Surgery
According to the American Society of Bariatric Surgery, the first report of a procedure designed to induce weight loss was published in 1954. Two surgeons by the name of Kremen and Linner described a procedure which involved connecting the upper part of the small intestine to the lower part of the small intestine. Essentially, this meant that food would “bypass” a large amount of the small intestine, including sections called the jejunum and the ileum. Patients could eat as much as they wanted, but only a small amount of the calories and nutrients would be absorbed by the body. The jejunoileal bypass (JIB), as it was called, pioneered the concept of malabsorption. Shortening the nutrient absorptive circuit remains the most powerful bariatric technique used today.
Unfortunately, the JIB can also be blamed for the negative or fearful attitude some people still have towards weight loss surgery. By the late 1960s and early 1970s, the procedure had become quite popular in the United States due to the dramatic and sustained weight loss it produced. But after long-term data accumulated, physicians discovered that it carried several distressing and even life-threatening complications. Patients regularly experienced diarrhea, electrolyte imbalances, anemia, vitamin deficiencies, malnutrition, gallstones, and a number of other adverse effects. But more frighteningly, some patients developed severe kidney and liver failure, leading to a number of deaths. As a result of its high risk, the JIB procedure was abandoned in favor of safer techniques. The procedure is no longer performed in the United States.
Biliopancreatic Diversion for Surgical Weight Loss
By the late 1970s, surgeons had learned from the JIB experience and gained an idea of what not to do for surgical weight loss. The next major bariatric surgical weight loss procedure to emerge came out of Italy in 1976. Dr. Nicola Scopinaro of the University of Genoa revised the JIB procedure so that most of the small intestine remained intact, thus reducing the chances of liver or kidney problems.
To achieve maximum weight loss, Scopinaro’s procedure used two components instead of one. First, approximately 2/3 of the stomach was removed to moderately restrict the amount of food that can be consumed at one time. Then the outlet of the stomach was connected to the final segment of the small intestine. By diverting food through this new “limb,” the nutrients were effectively separated from the bile and pancreatic enzymes that would break them down. As a result, BPD greatly reduced nutrient absorption and caloric intake.
The first to combine the restriction of food intake and malabsorption, BPD is also the first procedure to remain in usage (albeit limited) more than two decades after its advent. In 1996, Scopinaro reported that after 18 years of follow-up, his patients maintained an excess weight loss of 72%.2 According to the American Society of Bariatric Surgery, BPD has yielded the best long-term results published to date.
The BPD is also unique because it is the only current procedure that allows you to eat normal quantities of food and still achieve excellent weight loss. But there’s a catch. The procedure still carries some of the malabsorptive complications of JIB, including loose stools, malodorous gas, and serious deficiencies in protein and minerals such as calcium. BPD patients must take vitamin supplements for the rest of their lives to avoid malnutrition and bone demineralization.
In 1993, a group of Canadian doctors published the first results of a modification of the BPD procedure known as the biliopancreatic diversion with duodenal switch (BPDDS).3 The BPDDS preserves the pyloric valve that connects the stomach to the beginning portion of the small intestine. In addition, physicians increase the length of the small intestine left intact. As a result of these adjustments, this variant reportedly carries fewer complications but with comparable or greater weight loss.
Nonetheless, BPD is the still the most complicated and extreme bariatric surgical weight loss procedure in use. While it produces profound weight loss, it also carries a high risk of nutritional and metabolic problems. This led researchers to continue searching for an even safer approach for surgical weight loss. Presently, the BPD remains in use, especially in Europe, but is less popular in than some of the newer procedures available in the United States.
Gastroplasty (Stomach Stapling)
The science of “stapling” surgeries originated in World War II. To provide a rapid method of dealing with injuries sustained on the battlefield, the Russians developed surgical instruments which could staple body tissue together. Later, these instruments were refined into what’s used today.
Gastroplasty, or “stomach stapling,” represented the next wave of weight loss surgery in the early 1980s. Surgeons could now reduce the volume of the stomach without removing any portion of it. Instead, a staple line would hold the stomach tissue together to create a new wall. Three staples would be removed from the center of the line, however, to allow for a narrow passageway into the lower stomach. The pouch fills quickly and empties slowly with solid food, producing a feeling of fullness. Overeating results in pain or vomiting.
As a result, patients became full after eating only small amounts of food, due to the reduced stomach size and slower passage of food through the new, narrow stomach outlet, or stoma as a result of stomach stapling surgery. Those who had early gastroplasty-called horizontal gastroplasty-lost weight over the first few months, but at a certain point, doctors observed that they stopped losing weight or even regained weight. Doctors quickly determined that the stoma was stretching out over time in many patients.
To address this problem, Dr. Edward Mason at the University of Iowa developed a modification known as vertical banded gastroplasy (VBG) and published the first results in 1982. Mason decided to make the stapling line vertical instead of horizontal to capitalize on the thickest areas of the stomach wall-those least likely to stretch. In addition, he imposed strict measurements for the stomach pouch and placed a polypropylene band around the stoma to reinforce it. As a result, the rate of stoma enlargement decreased.
Compared to its predecessor, the VBG produced better results and fewer complications. Within a matter of time, it became the preferred method of gastroplasty. Because there is no malabsorptive component, patients do not generally encounter serious metabolic side effects or nutritional deficiencies. Weight loss-which can exceed 50% of excess body weight-occurs solely due to the restriction of food intake.
Unfortunately, despite the many improvements over the years, VBG still comes with a risk of weight regain as a late complication. Staple line disruption and shifting of the band can allow the stoma to expand years after surgery. Although not nearly as popular as it once was, the VBG remains in use today.
Minimal Incision Gastric Bypass
There are different approaches to accomplish operations. These approaches have been adapted for procedures in the abdomen as well as other areas of the body, such as the chest. They are:
Traditional Open Surgery
Minimally Invasive Surgery
– Minimal Incision
The Minimal incision approach falls within the category of minimally invasive surgery, as does Laparoscopic surgery. Both approaches minimize the incision length and thus reduce trauma and thus minimizes recovery time and postoperative pain. In minimal incision bariatric surgery, the same operation is accomplished as with traditional open surgery, however the incision size is greatly reduced, and are on the order of about 4 inches or 10 cm. The total length of the multiple small incisions used for laparoscopy and the length of the single small incision used for minimal incision surgery are about the same, and therefore the amount of pain and recovery time from both approaches are comparable.
Typically patients that have had their bariatric surgery through the minimal incision approach will leave the hospital on the 3rd hospital day (post-op day #2), which is as good or better than those that have the operation through the laparoscopic approach.
Adjustable Gastric Banding (Lap Band)
In the early 1990s, bariatric surgeons in Europe and Scandinavia were in the early stages of investigating another procedure that would eventually become the least invasive and traumatic bariatric surgery to date. For the first time, surgeons explored the idea of implanting a restrictive device instead of cutting or stapling the stomach to reduce its capacity.
The first device of this kind was the Swedish Adjustable Gastric Band (SAGB), patented in 1985 by Obtech Medical in Sweden. Essentially, a silicone band was placed around the upper stomach to create a tiny stomach pouch. As with VBG, the procedure restricted food intake by producing an earlier feeling of fullness. But unlike VBG, the new stomach outlet wasn’t as susceptible to stretching, and the patient could have the band removed (thus reversing the procedure) if desired.
The earliest versions of Swedish Adjustable Gastric Banding required open surgery and carried some problems. In addition, the weight loss results were not as good as the prevalent restrictive procedure, VBG. But the adjustable gastric banding concept soon regained momentum thanks to a modified version that surfaced in 1990 and included an inflatable balloon on the inner surface of the band. Tubing connected the balloon to a reservoir of liquid positioned beneath the skin. Using a needle, physicians could add or withdraw liquid to adjust the size of the band and, consequently, the rate of weight loss.
With the unique attributes of reversibility and adjustability, the gastric banding concept garnered even more interest. An American company, INAMED Health (Santa Barbara, CA), with 25 years of silicone manufacturing expertise, designed a next-generation version called the BioEnterics® LAP-BAND® Adjustable Gastric Banding System that could be implanted laparoscopically. The new design included multiple sized bands and accessories. As a result, the procedure became more accessible and patient-friendly due to its minimal invasiveness and shortened recovery. Patients could potentially stay just one night in the hospital and be home the following day.
In this procedure, a hollow band made of special material is placed around the stomach near its upper end, creating a small pouch and a narrow passage into the larger remainder of the stomach. The band is then inflated with a salt solution. It can be tightened or loosened over time to change the size of the passage by increasing or decreasing the amount of salt solution.
Laparoscopic Weight Loss Surgery
Laparoscopic operations are performed through several small incisions with the aid of a fiber-optic video camera and special instruments which can reduce the trauma and discomfort associated with a long open incision. Hospitalization, post-op pain, and recovery time is usually reduced compared to traditional surgery. Laparoscopic surgical obesity treatment operations have only been performed since 1993. Therefore the American Society of Bariatric Surgeons recommends choosing a surgeon who is experienced in both laparoscopic and open bariatric operations, and who understands the complexities of surgical treatment of obesity.
Restrictive Weight Loss Surgery Procedures
The theory is simple. When you feel full, you are more likely to have reduced feelings of hunger and will no longer feel deprived. The result is that you are likely to eat less. Restrictive weight loss surgery works by reducing the amount of food consumed at one time. It does not, however, interfere with the normal absorption (digestion) of food. In a restrictive procedure, the surgeon creates a smaller upper stomach pouch. The pouch, with a capacity of approximately 1/2 to 1 oz. (15 to 30 ml), connects to the rest of the stomach through an outlet known as a “stoma.” In a cooperative and compliant patient, the reduced stomach capacity, along with behavioral changes, can result in consistently lower caloric intake and consistent weight loss.
During recovery, patients must adhere to the strict specific dietary guidelines and restrictions their surgeon prescribes. While these guidelines may vary from one surgeon to the next, it is important for each patient to follow the surgeon’s guidelines. When the time comes to resume eating “regular” food, the patient must learn to adapt to a new way of eating. At each meal, they are restricted to consuming approximately 1/2 to a full cup of food before feeling uncomfortably full. Patients who see the best results from a restrictive procedure are those who learn to eat slowly, eat less, and avoid drinking too many fluids, particularly carbonated beverages.
If the patient fails to follow these guidelines, they can stretch the stomach pouch and/or the stoma outlet and defeat the purpose of the surgery. The effectiveness of a restrictive procedure is reduced by constant snacking or by drinking high-calorie, high-fat liquids. Failure to achieve the expected level of weight loss is usually the result of a patient failing to comply with the recommended dietary and behavior modifications, such as increased exercise and regular support group attendance.
Malabsorptive Weight Loss Surgery Procedures
It can be said that some of the restrictive approaches discussed have not always achieved the excess weight loss surgeons and patients anticipated. For this reason, weight loss surgery procedures that alter digestion, known as malabsorptive procedures, were developed to work in conjunction with restrictive approaches. Some of these weight loss surgery procedures involve a bypass of the small intestine, thus limiting the absorption of calories. On balance, malabsorptive or malabsorptive/restrictive weight loss surgery procedures have resulted in an overall increase in the loss of excess weight. The risk of complications and side effects generally increases with the lengthening of the small intestine bypass. You and your surgeon must determine the risks and benefits over your lifetime with the type of weight loss surgery procedures available.
Basically, weight loss operations fall into three categories:
- Restrictive procedures make the stomach smaller to limit the amount of food intake.
- Malabsorptive techniques reduce the amount of intestine that comes in contact with food so that the body absorbs fewer calories.
- Combination operations take advantage of both restriction and malabsorption.
Plastic Surgery Following Surgical Weight Loss
Some, but not all, surgical weight loss patients need plastic surgery following their procedures. Factors which contribute to need for follow-up plastic surgery include starting weight, how much weight you lose, age, skin elasticity, and response to exercise. Please note that most insurers will not pay for plastic surgery unless it is medically necessary due to a significant amount of excess skin. Please refer to the following links for more information about plastic surgery:
The American Society of Plastic Surgeons – The ASPS is the member society of plastic surgeons certified by the American Board of Plastic Surgery, which is recognized by the AMA. This web site has been designed to provide a variety of information about plastic surgery, from news on the latest advances and techniques to details of specific surgical procedures, including how to prepare for surgery after gastroplasty surgery, the types of anesthesia used and how long recovery takes. Look for answers to the most frequently asked questions about plastic surgery and statistics, including the average costs of various procedures.
American Society of Aesthetic Plastic Surgeons – This organization is also comprised of physicians certified by the American Board of Plastic Surgeons who specialize in cosmetic surgery of the face and body. This site contains a variety of information on cosmetic procedures, news publications on latest advances and studies in cosmetic surgery, as well as a doctor locator. Additionally, this site enables visitors to send questions to ASAPS surgeons and often posts quizzes for individuals interested in cosmetic surgery or solutions after gastroplasty surgery.
American Academy of Facial Plastic and Reconstructive Surgery – The AAFPRS is the member society of facial plastic surgeons certified by the American Board of Otolaryngology, which is recognized by the AMA. These surgeons specialize in procedures involving the head and neck. This site also provides procedure information, a doctor locator, and information about the association.
The American Society of Plastic Surgeons – This area offers a general overview of cosmetic surgery procedures. It details of specific surgical procedures, including how to prepare for surgery, the types of anesthesia used and how long recovery takes.
American Academy of Facial Plastic and Reconstructive Surgery – This link Includes general information for procedures involving the head and neck. Additionally, this includes FAQs, a glossary of medical terms, and before and after photos.
Andrew Hargroder, MD
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